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Facial contour reconstruction in localised lipodystrophy using free radial forearm adipofascial flaps
British Journal of' Plastic Surgery (1998), 51,499-502 9 1998 The British Association of Plastic Surgeons
I
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
Facial contour reconstruction in localised lipodystrophy using free radial forearm adipofascial flaps C. E. Koshy a n d J. Evans
Plastic Surgery and Burns Unit, Derr!/ord Hospital, Plymouth PL6 8DH, UK SUMMARY. U n i l a t e r a l facial c o n t o u r deformities in two patients with localised l i p o d y s t r o p h i e s were reconstructed with free radial f o r e a r m a d i p o f a s c i a l flaps. A t follow-up o f 5 a n d 4 years there is no significant d o w n w a r d gravitation, a n d the flaps have m a i n t a i n e d their integrity a n d bulk. B o t h the patients have h a d significant i m p r o v e m e n t in their self-consciousness o f a p p e a r a n c e . Since the d o n o r site was closed primarily, a linear f o r e a r m scar r e m a i n s the only d o n o r site morbidity.
she had loss of subcutaneous fat over the entire right cheek and markedly over the parotidomasseteric region, giving a hollow and sunken appearance with a prominent right facial skeleton (Fig. I A,B). This had led to low self-esteem and as a result she took to hiding her face in a long hairstyle. A free radial forearm adipofascial flap was raised incorporating the radial vessels (Fig. 1C). A thin layer of fat was left on the dermal flaps to preserve the sub-dermal vascular plexus. The tlap was inset into a subcutaneous pocket in the right cheek anastomosing to the superior thyroid vessels, and secured with pull through bolster sutures (Fig. I D). Her postoperative period was uneventful. At her first year follow-up the contour deformity seemed to be overcorrected and liposuction for recontouring was considered. This, however, was not carried out and the llap continued to settle down further. At 4 years she has a pleasing result (Fig. IE) and is currently working at a local superstore in a position very much open to public gaze. A thin linear forearm scar remains the only donor site morbidity (Fig. IF).
The l i p o d y s t r o p h i e s are rare a n d unusual conditions, in which the m o s t r e m a r k a b l e feature is a p a r t i a l or total a t r o p h y o f the s u b c u t a n e o u s fat. T h e i r cause is unclear. T h e y can be generalised or partial, a n d congenital (familial) or a c q u i r e d (sporadic). A c q u i r e d partial l i p o d y s t r o p h y is the m o s t c o m m o n o f the l i p o d y s t r o p h i e s a n d usually afl'ects women. Fat atrophy tends to occur in the u p p e r half o f the b o d y and spares the lower extremities. The age o f onset can be between c h i l d h o o d and a d u l t h o o d , and often follows all infective illness. The lesion o f the a d i p o s e tissue is benign in itself but there can be o t h e r associated disorders, such as renal disease, liver involvement, hypertension, insulin resistance and h y p e r t r i g l y c e r i d a e m i a , which m a y be p r o g n o s t i c a l l y serious.' Skeletal a s y m metry can occur s e c o n d a r y to the soft tissue atrophy. A variable a m o u n t o f fat is lost over an uncertain period o f time a n d then the process arrests, leaving the acquired deformities. T h e face is a l m o s t always involved, with taut stretching o f the skin rendering the n o r m a l facial skeleton p r o m i n e n t . Various techniques a n d materials have been used for facial c o n t o u r a u g m e n t a t i o n . Prosthetic materials like silastic prostheses and silicone injection p r o d u c e reactive i n f l a m m a t i o n a n d are prone to infections. ~ When the skin envelope a n d b o n y skeleton are n o r m a l as in lipodystrophy, a u t o l o g o u s vascularised a d i p o f a s cial tissue is the n a t u r a l choice, replacing like with like. Since d e r m i s is n o t i n c o r p o r a t e d in the a d i p o f a s c i a l flap it is soft a n d malleable, enabling it to be c o n t o u r e d to the shape o f the defect. The d o n o r site is closed primarily a n d hence there is no unsightly d o n o r site defect.
Case 2 (Fig. 2) A 44-year-old man presented with a facial contour d e f o f mity of his left lower cheek. His first symptoms appeared when he was 15 years of age and the fat atrophy progressed until 24 years of age when it spontaneously ceased. On examination he had a moderate degree of facial asymmetry due to atrophy of subcutaneous fat in his left lower cheek (Fig. 2A). This was causing him social embarrassment and he was anxious to improve his facial appearance. A free radial forearm adipofascial flap was raised and inset into a subcutaneous pocket in the left cheek approached through a submandibular incision with a short vertical extension. The external carotid artery and the external jugular vein were the recipient vessels. The flap was held in place with multiple pull through sutures. The donor site was closed primarily. He had to be taken back to theatre the same night to drain a haematoma under the flap. The swelling settled over the next few days and he was allowed home with a viable settling flap. On his first year follow-up, he had good restoration of his left cheek contour deformity, and the aesthetic result had made a tremendous improvement to his self confidence. Five years alter the operation the flap still maintains its integrity and bulk (Fig. 2B).
Case reports Case 1 (Fig. 1) A 14-year-old girl presented with progressive contour deti)rmity of her right cheek of 4 years" duration. On examination 499
500
Figure 1 (A) Preoperative view show!ng the lipodystrophy of the right cheek. (B) Preoperative profile view. (C) The forearm adipofascial flap is raised based on the radial vessels. (D) Immediately postoperative with the flap inset and secured with pull through bolster. (E) View at 4 years.
British Journal of Plastic Surgery
Facial contour reconstruction in localised lipodystrophy
Figure 1
501
(F) Profile view at 4 years. (G) Donor site at 4 ycars,
Discussion
Lipodystrophy is a relatively rare condition and very few reports are available in the literature regarding facial reconstruction in such patients. Transplantation of normal tissue to atrophic areas during the progressive stage of the disease causes atrophy of the transplanted adipocytes) Hence it is important to plan reconstruction only after the progressive atrophy has ceased. Site-specific properties of human adipose depots have been investigated in fresh cadavers with a view to guiding surgeons towards selecting sources for fat transplantation) Pond et al have shown that adipose tissues from different sites in the human body differ in relative adipocyte volume, collagen content and metabolic activity. The collagen content of the adipose tissue determines its vascularity, mechanical and tactile properties. The abdominal wall 'paunch'
Figure 2 (A) Preoperative view showing lipodystrophy of the left lower cheek. (B) View at 5 years.
depot, buttock fat depot and thigh fat depot have large adipocytes with low collagen content and low metabolic activity. These relatively metabolically inert fat depots would be suitable for large fat grafts. The biceps/triceps depot in the upper limb was significantly different from the thigh depot in having small adipocytes with high glycolytic activity. These
502 metabolically m o r e active depots would therefore be suitable only for m o d e r a t e sized grafts. Autologous fat grafts to treat facial depressions and scars have been reported since as early as 1909 (Lexer E). Ellenbogen in 19864 reported the use o f fat 'pearl' grafts to a u g m e n t facial post-traumatic defects, pitting acne, nasolabial folds, wrinkles, eyelid depressions and in chin augmentation. These 'pearl' grafts were between 4 and 6 m m in diameter. Large non-vascularised fat grafts have also been used in the past for a wide variety o f reconstructions. The results were unpredictable due to progressive fat resorption. 5 Silicone injections have been reported to give g o o d results with follow-ups up to 10 years. 6 The chances o f infection, i n f a m m a t o r y reaction and possibility o f an unnaturally firm texture preclude their use. With the advent o f microvascular surgery and free flap transfer, n u m e r o u s d o n o r tissues have been transferred. O m e n t u m , 7 groin flaps, 8,9 parascapular flaps, 1~ superficial inferior epigastric flaps, 1~ i n f r a - m a m m a r y extended circumflex scapular flaps H and T R A M flaps 12 are some o f them. D o n o r site deformity and p o o r calibre vascular pedicles are the m a j o r disadvantages o f m o s t o f these free flaps. Free microvascular adipofascial flaps maximise both d o n o r and recipient site aesthetics. A linear scar remains the only d o n o r site deformity. The fascial layer o f the flap n o t only ensures the integrity o f the thin vascular plexuses on either side o f it but m a y also contribute to maintaining the integrity o f the fat layer. The long reliable and large calibre pedicle allows flexibility in placing the facial incisions. The entire surgical procedure can be done in the supine position. Large flaps have a tendency to move downwards under the effects o f gravity. This gravitational pull can be stopped with periosteal suturing o f the flap or by using anchoring devices that a n c h o r flaps to bone. Adipofascial transfer is possible only if the facial skin is not involved. Since the volume o f adipofascial tissue in the forearm is limited the free radial forearm adipofascial flap m a y only be appropriate for moderate sized c o n t o u r deformities.
Conclusion
A u t o l o g o u s adipose tissue is the m o s t appropriate and natural replacement for soft tissue defects. The free radial f o r e a r m adipofascial flap is an alternative
British Journal of Plastic Surgery for reconstruction o f m o d e r a t e sized facial c o n t o u r deformities. G o o d aesthetic results are possible at b o t h recipient a n d d o n o r sites.
References
1. Foster DW. The lipodystrophies and other rare disorders of adipose tissue. In: Harrison's Principles of Internal Medicine, 14th Edn. 1998; Chap. 352: 2209-12. 2. Smith AA, Manktelow RT. The use of free tissue transfer to restore facial contour. Clin Plast Surgery 1990; 17:655 61. 3. Pond CM, Mattacks CA, Calder PC, Evans J. Site-specific properties of human adipose depots homologous to those of other mammals. Comp Biochem Physiol 1993; 104A: 819-24. 4. Ellenbogen R. Free autogenous pearl fat grafts in the face: a preliminary report of a rediscovered technique. Ann Plast Surg 1986; 16:179 94. 5. Billings E Jr, May JW Jr. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989; 83: 368-81. 6. Rees TD, Ashley FL, Delgado JR Silicone fluid injections for facial atrophy: a ten-year study. Plast Reconstr Surg 1973; 52: 118-27. 7. Jurkiewicz M J, Nahai E The use of free revascularized grafts in the amelioration of hemifacial atrophy. Plast Reconstr Surg 1985; 76: 44-55. 8. Harashina T, Nakajima T, Yoshimura 5( A free groin flap reconstruction in progressive facial hemiatrophy. Br J Plast Surg 1977; 30:14 16. 9. Dunkley MP, Stevenson JH. Experience with the free "inverted" groin flap in facial soft tissue contouring: a report on 6 flaps. Br J Plast Surg 1990;43: 154-8. 10. Upton J, Albin RE, Mulliken JB, Murray JE. The use of scapular and parascapular flaps for cheek reconstruction. Plast Reconstr Surg 1992; 90:959 71. 11. Longaker MT, Flynn A, Siebert JW. Microsurgical correction of bilateral facial contour deformities. Plast Reconstr Surg 1996; 98:951 7. 12. Coessens BC, Van Geertruyden JR Simultaneous bilateral facial reconstruction of a Barraquer-Simons lipodystrophy with free TRAM flaps. Plast Reconstr Surg 1995; 95: 911-15.
The Authors c. E. Koshy MS, DNB, FRCSI, Specialist Registrar Judy Evans MA, FRCSEd FRCS (Plast), Consultant Plastic Surgeon
Plastic and Reconstructive Surgery, Derriford Hospital, Plymouth PL6 8DH, UK. Correspondence to Dr Judy Evans. Paper received 22 April 1998. Accepted 22 July 1998.
I
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
Facial contour reconstruction in localised lipodystrophy using free radial forearm adipofascial flaps C. E. Koshy a n d J. Evans
Plastic Surgery and Burns Unit, Derr!/ord Hospital, Plymouth PL6 8DH, UK SUMMARY. U n i l a t e r a l facial c o n t o u r deformities in two patients with localised l i p o d y s t r o p h i e s were reconstructed with free radial f o r e a r m a d i p o f a s c i a l flaps. A t follow-up o f 5 a n d 4 years there is no significant d o w n w a r d gravitation, a n d the flaps have m a i n t a i n e d their integrity a n d bulk. B o t h the patients have h a d significant i m p r o v e m e n t in their self-consciousness o f a p p e a r a n c e . Since the d o n o r site was closed primarily, a linear f o r e a r m scar r e m a i n s the only d o n o r site morbidity.
she had loss of subcutaneous fat over the entire right cheek and markedly over the parotidomasseteric region, giving a hollow and sunken appearance with a prominent right facial skeleton (Fig. I A,B). This had led to low self-esteem and as a result she took to hiding her face in a long hairstyle. A free radial forearm adipofascial flap was raised incorporating the radial vessels (Fig. 1C). A thin layer of fat was left on the dermal flaps to preserve the sub-dermal vascular plexus. The tlap was inset into a subcutaneous pocket in the right cheek anastomosing to the superior thyroid vessels, and secured with pull through bolster sutures (Fig. I D). Her postoperative period was uneventful. At her first year follow-up the contour deformity seemed to be overcorrected and liposuction for recontouring was considered. This, however, was not carried out and the llap continued to settle down further. At 4 years she has a pleasing result (Fig. IE) and is currently working at a local superstore in a position very much open to public gaze. A thin linear forearm scar remains the only donor site morbidity (Fig. IF).
The l i p o d y s t r o p h i e s are rare a n d unusual conditions, in which the m o s t r e m a r k a b l e feature is a p a r t i a l or total a t r o p h y o f the s u b c u t a n e o u s fat. T h e i r cause is unclear. T h e y can be generalised or partial, a n d congenital (familial) or a c q u i r e d (sporadic). A c q u i r e d partial l i p o d y s t r o p h y is the m o s t c o m m o n o f the l i p o d y s t r o p h i e s a n d usually afl'ects women. Fat atrophy tends to occur in the u p p e r half o f the b o d y and spares the lower extremities. The age o f onset can be between c h i l d h o o d and a d u l t h o o d , and often follows all infective illness. The lesion o f the a d i p o s e tissue is benign in itself but there can be o t h e r associated disorders, such as renal disease, liver involvement, hypertension, insulin resistance and h y p e r t r i g l y c e r i d a e m i a , which m a y be p r o g n o s t i c a l l y serious.' Skeletal a s y m metry can occur s e c o n d a r y to the soft tissue atrophy. A variable a m o u n t o f fat is lost over an uncertain period o f time a n d then the process arrests, leaving the acquired deformities. T h e face is a l m o s t always involved, with taut stretching o f the skin rendering the n o r m a l facial skeleton p r o m i n e n t . Various techniques a n d materials have been used for facial c o n t o u r a u g m e n t a t i o n . Prosthetic materials like silastic prostheses and silicone injection p r o d u c e reactive i n f l a m m a t i o n a n d are prone to infections. ~ When the skin envelope a n d b o n y skeleton are n o r m a l as in lipodystrophy, a u t o l o g o u s vascularised a d i p o f a s cial tissue is the n a t u r a l choice, replacing like with like. Since d e r m i s is n o t i n c o r p o r a t e d in the a d i p o f a s c i a l flap it is soft a n d malleable, enabling it to be c o n t o u r e d to the shape o f the defect. The d o n o r site is closed primarily a n d hence there is no unsightly d o n o r site defect.
Case 2 (Fig. 2) A 44-year-old man presented with a facial contour d e f o f mity of his left lower cheek. His first symptoms appeared when he was 15 years of age and the fat atrophy progressed until 24 years of age when it spontaneously ceased. On examination he had a moderate degree of facial asymmetry due to atrophy of subcutaneous fat in his left lower cheek (Fig. 2A). This was causing him social embarrassment and he was anxious to improve his facial appearance. A free radial forearm adipofascial flap was raised and inset into a subcutaneous pocket in the left cheek approached through a submandibular incision with a short vertical extension. The external carotid artery and the external jugular vein were the recipient vessels. The flap was held in place with multiple pull through sutures. The donor site was closed primarily. He had to be taken back to theatre the same night to drain a haematoma under the flap. The swelling settled over the next few days and he was allowed home with a viable settling flap. On his first year follow-up, he had good restoration of his left cheek contour deformity, and the aesthetic result had made a tremendous improvement to his self confidence. Five years alter the operation the flap still maintains its integrity and bulk (Fig. 2B).
Case reports Case 1 (Fig. 1) A 14-year-old girl presented with progressive contour deti)rmity of her right cheek of 4 years" duration. On examination 499
500
Figure 1 (A) Preoperative view show!ng the lipodystrophy of the right cheek. (B) Preoperative profile view. (C) The forearm adipofascial flap is raised based on the radial vessels. (D) Immediately postoperative with the flap inset and secured with pull through bolster. (E) View at 4 years.
British Journal of Plastic Surgery
Facial contour reconstruction in localised lipodystrophy
Figure 1
501
(F) Profile view at 4 years. (G) Donor site at 4 ycars,
Discussion
Lipodystrophy is a relatively rare condition and very few reports are available in the literature regarding facial reconstruction in such patients. Transplantation of normal tissue to atrophic areas during the progressive stage of the disease causes atrophy of the transplanted adipocytes) Hence it is important to plan reconstruction only after the progressive atrophy has ceased. Site-specific properties of human adipose depots have been investigated in fresh cadavers with a view to guiding surgeons towards selecting sources for fat transplantation) Pond et al have shown that adipose tissues from different sites in the human body differ in relative adipocyte volume, collagen content and metabolic activity. The collagen content of the adipose tissue determines its vascularity, mechanical and tactile properties. The abdominal wall 'paunch'
Figure 2 (A) Preoperative view showing lipodystrophy of the left lower cheek. (B) View at 5 years.
depot, buttock fat depot and thigh fat depot have large adipocytes with low collagen content and low metabolic activity. These relatively metabolically inert fat depots would be suitable for large fat grafts. The biceps/triceps depot in the upper limb was significantly different from the thigh depot in having small adipocytes with high glycolytic activity. These
502 metabolically m o r e active depots would therefore be suitable only for m o d e r a t e sized grafts. Autologous fat grafts to treat facial depressions and scars have been reported since as early as 1909 (Lexer E). Ellenbogen in 19864 reported the use o f fat 'pearl' grafts to a u g m e n t facial post-traumatic defects, pitting acne, nasolabial folds, wrinkles, eyelid depressions and in chin augmentation. These 'pearl' grafts were between 4 and 6 m m in diameter. Large non-vascularised fat grafts have also been used in the past for a wide variety o f reconstructions. The results were unpredictable due to progressive fat resorption. 5 Silicone injections have been reported to give g o o d results with follow-ups up to 10 years. 6 The chances o f infection, i n f a m m a t o r y reaction and possibility o f an unnaturally firm texture preclude their use. With the advent o f microvascular surgery and free flap transfer, n u m e r o u s d o n o r tissues have been transferred. O m e n t u m , 7 groin flaps, 8,9 parascapular flaps, 1~ superficial inferior epigastric flaps, 1~ i n f r a - m a m m a r y extended circumflex scapular flaps H and T R A M flaps 12 are some o f them. D o n o r site deformity and p o o r calibre vascular pedicles are the m a j o r disadvantages o f m o s t o f these free flaps. Free microvascular adipofascial flaps maximise both d o n o r and recipient site aesthetics. A linear scar remains the only d o n o r site deformity. The fascial layer o f the flap n o t only ensures the integrity o f the thin vascular plexuses on either side o f it but m a y also contribute to maintaining the integrity o f the fat layer. The long reliable and large calibre pedicle allows flexibility in placing the facial incisions. The entire surgical procedure can be done in the supine position. Large flaps have a tendency to move downwards under the effects o f gravity. This gravitational pull can be stopped with periosteal suturing o f the flap or by using anchoring devices that a n c h o r flaps to bone. Adipofascial transfer is possible only if the facial skin is not involved. Since the volume o f adipofascial tissue in the forearm is limited the free radial forearm adipofascial flap m a y only be appropriate for moderate sized c o n t o u r deformities.
Conclusion
A u t o l o g o u s adipose tissue is the m o s t appropriate and natural replacement for soft tissue defects. The free radial f o r e a r m adipofascial flap is an alternative
British Journal of Plastic Surgery for reconstruction o f m o d e r a t e sized facial c o n t o u r deformities. G o o d aesthetic results are possible at b o t h recipient a n d d o n o r sites.
References
1. Foster DW. The lipodystrophies and other rare disorders of adipose tissue. In: Harrison's Principles of Internal Medicine, 14th Edn. 1998; Chap. 352: 2209-12. 2. Smith AA, Manktelow RT. The use of free tissue transfer to restore facial contour. Clin Plast Surgery 1990; 17:655 61. 3. Pond CM, Mattacks CA, Calder PC, Evans J. Site-specific properties of human adipose depots homologous to those of other mammals. Comp Biochem Physiol 1993; 104A: 819-24. 4. Ellenbogen R. Free autogenous pearl fat grafts in the face: a preliminary report of a rediscovered technique. Ann Plast Surg 1986; 16:179 94. 5. Billings E Jr, May JW Jr. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989; 83: 368-81. 6. Rees TD, Ashley FL, Delgado JR Silicone fluid injections for facial atrophy: a ten-year study. Plast Reconstr Surg 1973; 52: 118-27. 7. Jurkiewicz M J, Nahai E The use of free revascularized grafts in the amelioration of hemifacial atrophy. Plast Reconstr Surg 1985; 76: 44-55. 8. Harashina T, Nakajima T, Yoshimura 5( A free groin flap reconstruction in progressive facial hemiatrophy. Br J Plast Surg 1977; 30:14 16. 9. Dunkley MP, Stevenson JH. Experience with the free "inverted" groin flap in facial soft tissue contouring: a report on 6 flaps. Br J Plast Surg 1990;43: 154-8. 10. Upton J, Albin RE, Mulliken JB, Murray JE. The use of scapular and parascapular flaps for cheek reconstruction. Plast Reconstr Surg 1992; 90:959 71. 11. Longaker MT, Flynn A, Siebert JW. Microsurgical correction of bilateral facial contour deformities. Plast Reconstr Surg 1996; 98:951 7. 12. Coessens BC, Van Geertruyden JR Simultaneous bilateral facial reconstruction of a Barraquer-Simons lipodystrophy with free TRAM flaps. Plast Reconstr Surg 1995; 95: 911-15.
The Authors c. E. Koshy MS, DNB, FRCSI, Specialist Registrar Judy Evans MA, FRCSEd FRCS (Plast), Consultant Plastic Surgeon
Plastic and Reconstructive Surgery, Derriford Hospital, Plymouth PL6 8DH, UK. Correspondence to Dr Judy Evans. Paper received 22 April 1998. Accepted 22 July 1998.